Comment

Serious hazards

SHOT director Dr Paula Bolton-Maggs gives an update from the national haemovigilance reporting scheme, Serious Hazards of Transfusion (SHOT).

The risks of adverse events after transfusion are fortunately low, but not absent. Infection is very rare compared to errors in the process.

Adverse events in relation to blood transfusion are reported to SHOT throughout the year. In January each year the writers collate their data on the different classes of events in order to publish the annual report in July, in association with a national symposium which this year is on Wednesday July 10 at the Royal Society of Medicine in London.

Pathological events may not be predictable and it is essential that every blood transfusion is justifi ed and properly monitored. Recent national audit of transfusion in medical patients suggests that many may be unnecessary.

Fortunately deaths from transfusion are rare, but patients can also suffer morbidity from adverse events, such as cardiac failure if overtransfused. About half of all the reported events year-on-year are caused by mistakes and are therefore potentially avoidable.

SHOT have been noting for several years the critical importance of identifying the correct patient at every stage in the process, and the dangers of making assumptions. The SHOT team met with the GMC to discuss the importance of correct patient identifi cation. A transfusion awareness campaign – ‘Do you know who I am?’ – has been launched by the NHSBT to emphasise this with teaching materials and posters (www. transfusionguidelines.org).

It is SHOT’s strong view that a transfusion checklist should be implemented for every transfusion to confi rm all steps are correctly completed. This would be likely to reduce errors as has been shown by the introduction of the WHO surgical checklist. The GMC also remind us of our duty in healthcare to report all adverse events and perform a root cause analysis so that the error rates can be reduced.

The education subgroup of the National Blood Transfusion Committee has been working hard to examine the current medical undergraduate, postgraduate and speciality curricula for content on transfusion and will be making recommendations. It has been more challenging to examine the nursing curricula which are devolved from the Royal College of Nursing and Royal College of Midwives to local arrangements. At the same time competency training is being reassessed since this without a thorough understanding and knowledge of the principles or transfusion will not result in a reduction in mistakes.

With ‘pathology modernisation’ many changes and mergers are taking place. While automation removes the potential errors associated with manual techniques there is still a need for senior laboratory staff with proper understanding of transfusion laboratory procedures.

SHOT data demonstrate that IT systems are not foolproof and must be properly set up and used to be effective. The UK Transfusion Laboratory Collaborative is taking steps to survey again the staffi ng and training within laboratories, and interactive educational modules are being developed within the UK National Quality Assurance Scheme.

Pregnant women who are RhD negative are at risk of developing anti-D which may compromise future pregnancies unless they receive timely treatment with anti-D after potentially sensitising events, and prophylaxis during pregnancy.

Cumulative SHOT reporting demonstrates that most errors are made by midwives and there is a need for better education and training. A paper is in press in the British Journal of Obstetrics and Gynaecology about this issue, and a new survey is in place at SHOT to review those women who develop a new immune anti-D.

There have been recent concerns in France over the use of the methylene-blue sterilisation method for fresh frozen plasma, and it has been withdrawn there. There has not been any increase in reports in the UK related to this type of plasma when compared with standard fresh frozen plasma and there is no change in policy recommended at present.

SHOT continues to work closely with MHRA (who are required by law to report to the EU on issues of quality and collect similar but not identical reports to SHOT). We are working towards a unifi ed system for haemovigilance reporting which will be easier for the reporters.

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